A history of the treatment of craniopharyngiomas

Current Advances in the Management of Adult Craniopharyngiomas

Craniopharyngiomas (CPs) are slow growing, histologically benign intracranial tumors located in the sellar–suprasellar region. Although known to have low mortality, their location and relationship to the adjacent neural structures results in patients having significant neurologic, endocrine, and visual comorbidities. The invasive nature of this tumor makes complete resection a challenge and contributes to its recurrence. Additionally, these tumors are bimodally distributed, being treated with surgery, and are followed by other adjuncts, such as focused radiation therapy, e.g., Gamma knife. Advances in surgical techniques, imaging tools, and instrumentations have resulted in the evolution of surgery using endoscopic techniques, with residual components being treated by radiotherapy to target the residual tumor. Advances in molecular biology have elucidated the main pathways involved in tumor development and recurrence, but presently, no other treatments are offered to patients, besides surgery, radiation, and endocrine management, as the disease and tumor evolve. We review the contemporary management of these tumors, from the evolution of surgical treatments, utilizing standard open microscopic approaches to the more recent endoscopic surgery, and discuss the current recommendations for care of these patients. We discuss the developments in radiation therapy, such as radiosurgery, being used as treatment strategies for craniopharyngioma, highlighting their beneficial effects on tumor resections while decreasing the rates of adverse outcomes. We also outline the recent chemotherapy modalities, which help control tumor growth, and the immune landscape on craniopharyngiomas that allow the development of novel immunotherapies.

Endocrine Disorder in Patients With Craniopharyngioma

Craniopharyngioma is an intracranial congenital epithelial tumor growing along the pathway of the embryonic craniopharyngeal tube. The main clinical symptoms of patients with craniopharyngioma include high intracranial pressure, visual field defect, endocrine dysfunction, and hypothalamic dysfunction. At present, the preferred treatment remains the surgical treatment, but the recovery of endocrine and hypothalamic function following surgery is limited. In addition, endocrine disorders often emerge following surgery, which seriously reduces the quality of life of patients after operation. So far, research on craniopharyngioma focuses on ways to ameliorate endocrine dysfunction. This article reviews the latest research progress on pathogenesis, manifestation, significance, and treatment of endocrine disorders in patients with craniopharyngioma.

Endoscopic Transcortical Transventricular Management of Cystic Craniopharyngioma: Outcome Analysis of 32 Cases at a Tertiary Care Center

Background

Microsurgical resection has been considered the gold standard treatment of craniopharyngioma, but lately, it has found less favor due to its morbidity and is being replaced by minimally invasive cyst drainage procedures. We present our experience of transventricular endoscopy and cyst drainage along with its technique and have analyzed its results.

Materials and Methods

Clinical and radiological data of all cystic craniopharyngioma patients treated by transventricular endoscopic cyst drainage and Ommaya placement were retrieved and analyzed.

Results

Thirty-two patients underwent endoscopic cyst drainage during the study period. All patients had immediate clinical and radiological improvement. No significant complications were seen. All patients underwent adjuvant radiotherapy and six patients (18.7%) showed recurrence. Three patients died in the follow-up period.

Conclusions

Endoscopic transcortical transventricular cyst drainage with Ommaya reservoir along with adjuvant radiotherapy is a simple, safe, and effective treatment modality.

The safety and efficacy of endoscopic endonasal approach in the treatment of recurrent craniopharyngioma: A protocol for systematic review and meta-analysis

BACKGROUND

Craniopharyngioma is the most challenging brain tumor with a high recurrence rate. Some scholars have shown that endoscopic endonasal approach (EEA) can achieve a higher total tumor resection rate and significantly reduce the incidence of complications and mortality. However, there is still no consensus on the surgical approach for recurrent craniopharyngioma. The purpose of this study is to evaluate the safety and efficacy of EEA in the treatment of recurrent craniopharyngioma.

METHODS

We will search 7 electronic databases (PubMed, EMBASE, Web of Science, the Cochrane Library, PsycINFO, AMED, Scopus) to collect related randomized controlled trials (RCTs). The resection rate, recurrence rate and progression-free survival rate will be regarded as the primary outcome, and the incidence of complications will be regarded as the secondary outcome. Endnote Software X9.0 will be used to filter articles, Review Manager Software 5.2 and STATA software 16.0 will be used for analysis and synthesis.

RESULTS

We will integrate existing studies to assess the safety and efficacy of EEA in the treatment of recurrent craniopharyngioma.

CONCLUSION

Our study will provide EEA as an effective and safe treatment for recurrent craniopharyngioma.

REGISTRATION NUMBER

International Prospective Register of Systematic Reviews (PROSPERO): CRD42020199860.

Comparing survival outcomes of gross total resection and subtotal resection with radiotherapy for craniopharyngioma: a meta-analysis

BACKGROUND

Recent studies suggest that subtotal resection (STR) followed by radiation therapy (RT) is an appealing alternative to gross total resection (GTR) for craniopharyngioma, but it remains controversial. We conducted a meta-analysis to determine whether GTR is superior to STR with RT for craniopharyngioma.

MATERIALS AND METHODS

A systematic search was performed for articles published until October 2017 in the PubMed, Embase, and Cochrane Central databases. The endpoints of interest are overall survival and progression-free survival. Pooled hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) were calculated using a fixed or random-effects model. The data were analyzed using Review Manager 5.3 software.

RESULTS

A total of 744 patients (seven cohort studies) were enrolled for analyses. There were no significant differences between the GTR and STR with RT groups when the authors compared the pooled HRs at the end of the follow-up period. Overall survival (pooled HR = 0.76, 95% CI: 0.46-1.25, P = 0.28) and progression-free survival (pooled HR = 1.52, 95% CI: 0.42-5.44, P = 0.52) were similar between the two groups.

CONCLUSIONS

The current meta-analysis suggests that GTR and STR with RT have the similar survival outcomes for craniopharyngioma.

Clinical Outcome After Extended Endoscopic Endonasal Resection of Craniopharyngiomas: Two-Institution Experience

BACKGROUND

The extended endoscopic endonasal approach (EEA) to the anterior cranial base is used for the resection of craniopharyngiomas.

OBJECTIVE

We present clinical experience and outcomes of using EEA for craniopharyngiomas.

METHODS

A total of 116 patients in 2 remote institutions were enrolled in this retrospective study. Surgical, endocrinologic, and ophthalmologic outcomes were assessed.

RESULTS

The mean follow-up was 35 months (range, 1-115). Gross total resection (GTR), near total resection (NTR, >95%), and subtotal resection (STR) were achieved in 46%, 39%, and 15% of the patients, respectively. Surgery performed after 2010 was the only variable significantly associated with greater extent of resection, which might be explained by the learning curve. Overall tumor recurrence rate was 15.5%, with a median interval until recurrence of 14.5 months (range, 3-58). Extent of resection was significantly associated with recurrence-free survival (P = 0.0116). Those who underwent NTR/STR followed by adjuvant radiotherapy had a similar median recurrence-free survival rate compared with those who underwent GTR (26.5 vs. 20 months, P = 0.167). Endocrinologic examination revealed that 47.4% of patients experienced worsening of anterior pituitary function following surgery while 25.5% developed new-onset diabetes insipidus. Of the 89 patients with preoperative visual deficits, 68 (76.4%) experienced improvement in visual field assessment.

CONCLUSION

EEA is effective for the surgical resection of craniopharyngiomas, resulting in high rates of visual improvement and low complication rates. Adjuvant radiotherapy is a useful method for tumor control after incomplete resection.

The learning curve in endoscopic endonasal resection of craniopharyngiomas

OBJECTIVE There is a paucity of literature regarding the learning curve associated with performing endoscopic endonasal cranial base surgery. The purpose of this study was to determine to what extent a learning curve might exist for endoscopic endonasal resection in cases of craniopharyngiomas. METHODS A retrospective review was performed for all endoscopic endonasal craniopharyngioma resections performed at Thomas Jefferson University from 2005 to 2015. To assess for a learning curve effect, patients were divided into an early cohort (2005-2009, n = 20) and a late cohort (2010-2015, n = 23). Preoperative demographics, clinical presentation, imaging characteristics, extent of resection, complications, tumor control, and visual and endocrine outcomes were obtained. Categorical variables and continuous variables were compared using a 2-sided Fisher's exact test and t-test, respectively. RESULTS Only the index operation performed at the authors' institution was included. There were no statistically significant differences between early and late cohorts in terms of patient age, sex, presenting symptoms, history of surgical or radiation treatment, tumor size or consistency, hypothalamic involvement, or histological subtype. The rate of gross-total resection (GTR) increased over time from 20% to 65% (p = 0.005), and the rate of subtotal resection decreased over time from 40% to 13% (p = 0.078). Major neurological complications, including new hydrocephalus, meningitis, carotid artery injury, or stroke, occurred in 6 patients (15%) (8 complications) in the early cohort compared with only 1 (4%) in the late cohort (p = 0.037). CSF leak decreased from 40% to 4% (p = 0.007). Discharge to home increased from 64% to 95% (p = 0.024). Visual improvement was high in both cohorts (88% [early cohort] and 81% [late cohort]). Rate of postoperative panhypopituitarism and permanent diabetes insipidus both increased from 50% to 91% (p = 0.005) and 32% to 78% (p = 0.004), which correlated with a significant increase in intentional stalk sacrifice in the late cohort (from 0% to 70%, p < 0.001). CONCLUSIONS High rates of near- or total resection and visual improvement can be achieved using an endoscopic endonasal approach for craniopharyngiomas. However, the authors did find evidence for a learning curve. After 20 cases, they found a significant decrease in major neurological complications and significant increases in the rates of GTR rate and discharge to home. Although there was a large decrease in the rate of postoperative CSF leak over time, this was largely attributable to the inclusion of very early cases prior to the routine use of vascularized nasoseptal flaps. There was a significant increase in new panhypopituitarism and diabetes insipidus, which is attributable to increase rates of intentional stalk sacrifice.

Endoscopic extended transsphenoidal resection of craniopharyngiomas: nuances of neurosurgical technique

Endoscopic approaches to the midline ventral skull base have been extensively developed and refined for resection of cranial base tumors over the past several years. As these techniques have improved, both the degree of resection and complication rates have proven comparable to those for transcranial approaches, while visual outcomes may be better via endoscopic endonasal surgery and hospital stays and recovery times are often shorter. Yet for all of the progress made, the steep learning curve associated with these techniques has hampered more widespread implementation and adoption. The authors address this obstacle by coupling a thorough description of the technical nuances for endoscopic endonasal craniopharyngioma resection with detailed illustrations of the important steps in the operation. Traditionally, transsphendoidal approaches to craniopharyngiomas have been restricted to lesions mostly confined to the sella. However, recently, endoscopic endonasal resections are more frequently employed for extrasellar and purely third ventricle craniopharyngiomas, whose typical retrochiasmatic location makes them ideal candidates for endoscopic transnasal surgery. The endonasal endoscopic approach offers many advantages, including direct access to the long axis of the tumor, early tumor debulking with minimal manipulation of the optic apparatus, more precise visualization of tumor planes, particularly along the undersurface of the chiasm and the roof of the third ventricle, and a minimal-access corridor that obviates the need for brain retraction. Although much emphasis has been placed on technical tenets of exposure and "how to get there," this article focuses on nuances of tumor resection "when you are there." Three operative videos illustrate our discussion of technical tenets.

Recurrent craniopharyngioma after conformal radiation in children and the burden of treatment

OBJECT

In this paper the authors present their experience treating children with recurrent craniopharyngioma who were initially managed with surgery followed by conformal radiation therapy (CRT).

METHODS

A departmental oncology information system was queried to identify all children (< 18 years old) who received CRT for a craniopharyngioma between 1998 and 2010 (inclusive) and specifically those who experienced tumor progression. For each patient, the authors recorded the type of recurrence (solid, cystic, or both), the time interval to first progression and each subsequent progression, the associated treatment complications, and disease status at last follow-up evaluation.

RESULTS

Among the 97 patients that met criteria for entry into this study, 18 (18.6%) experienced tumor progression (9 cystic, 3 solid, 6 cystic and solid). The median time to first recurrence was 4.62 years (range 1.81-9.11 years). The subgroup included 6 female and 12 male patients with a median age of 7.54 years (range 3.61-13.83 years). Ten patients experienced first progression within 5 years of CRT. The 5- and 10-year treatment-free survival rates for the entire cohort were 89.0% (95% confidence interval [CI] 80.5%-93.9%) and 76.2% (95% CI 64%-85%), respectively. Seven patients had a single episode of progression and 11 had more than 1. The time interval between each subsequent progression was progressively shorter. The 18 patients underwent 38 procedures. The median follow-up duration for this group was 9.32 years (range 4.04-19.0 years). Three patients died, including 1 from perioperative complications.

CONCLUSIONS

Craniopharyngioma progression after prior irradiation is exceedingly difficult to treat and local control is challenging despite repeated surgical procedures. Given our results, gross-total resection may need to be the surgical goal at the time of first recurrence, if possible. Decompressing new cyst formation alone has a low rate of long-term success.

Development of intracranial approaches for craniopharyngiomas: an analysis of the first 160 historical procedures

Object

The development of surgical procedures for the removal of craniopharyngiomas (CPs) was greatly influenced by the enormous topographical and morphological heterogeneity displayed by these lesions. In this study the authors reviewed the intracranial approaches designed to treat CPs during the early historical period (1891–1938) with the aim of finding the CP topographical and pathological features that influence patient outcomes.

Methods

The authors conducted a systematic retrospective review of well-described cases of surgically treated CPs in publications from the period 1891–1938. Valuable information regarding the diagnosis of the lesion, type of craniotomy performed, CP topography, and outcome was selected from 418 reports included in medical publications from this period. The type of surgical procedure used, degree of tumor removal, CP position and histological variety, and clinical evidence of postoperative hypothalamic injury were the variables analyzed with the aim of defining their influence on the final patient outcome.

Results

A collection of 160 cases was eligible for analysis. Craniopharyngioma topography was significantly related to the existence of postoperative hypothalamic damage and the degree of tumor removal achieved (p < 0.001). The infundibulo-tuberal, or not strictly intraventricular, topography was associated with the highest rate of hypothalamic injury (84%) and impossibility of tumor removal (51%). This topography also showed the worst prognosis (p = 0.001). Additional variables correlated with patient outcome were the presence of hypothalamic damage, type of surgical approach used, and degree of tumor removal. Patients having a poor outcome, suffering from permanent coma, or dying after surgery presented with symptoms of hypothalamic injury in 40% of cases (p < 0.001). The surgical approach associated with the best outcome was the transsphenoidal (58%), followed by the subfrontal (45%) and the transcallosal (45%). Subtotal resection of the lesion yielded the best postoperative results, with only 17% of patients dying or suffering from a poor outcome, in contrast to the 39% reported for gross-total removal of the lesion (p = 0.001).

Conclusions

Two major variables influenced the results of early surgical experience with CPs for the period from 1891 to 1938: 1) the inaccuracy in defining CP topography with the diagnostic methods available at that time; and 2) the ignorance about the risks associated with the dissection of lesions showing tenacious adherence to the hypothalamus. The degree of functional and morphological disturbance of the hypothalamus caused by a CP remains a fundamental variable helping the surgeon to predict the risks associated with the radical excision of the tumor and patient outcome.

Radiological features of craniopharyngiomas located in the posterior fossa

BACKGROUND AND PURPOSE

Posterior fossa craniopharyngiomas (PFCP) constitute 1.6-4% of all craniopharyngiomas and have long been neglected. The purpose of our study was to investigate neuroimaging features of this unique modality in a cohort of 7 cases.

METHODS

CT and/or MR imaging features (with and without contrast enhancement) of 7 patients who underwent craniotomies for histologically proved PFCP were reviewed and analyzed retrospectively. Surgical management was also reviewed.

RESULTS

All PFCPs arised from sellar/suprasellar region and extended into unilateral cerebellopontine angle in 6 cases, and bilateral in 1 case. Seven tumors were of retrochiasmatic origin and 5 of 7 were of retrostalk growth pattern with location in the ventral area of brain stem. On CT scans, tumors were isodense in solid component and hypodense in cystic component with (4/7) or without calcification (3 /7) and destruction in sellae turcia (2/7). Tumors demonstrated cyst formation (7/7) with hypointense on T1-weighted imaging and hyperintense on T2-weighted imaging in 5 cases, hyperintense both on T1- and T2-weighted imaging in 2 cases. The solid components and capsule revealed mild to moderate inhomogeneous enhancement after administration of contrast agents. Total tumor removal was accomplished in 5 cases, subtotal removal and partial removal in 1 case respectively.

CONCLUSIONS

PFCPs are well demarcated, contrast-enhanced tumors, typically with cystic parts or purely cyst. Most of PFCPs demonstrate a retrostalk growth pattern and characteristic connection. Tumor with cystic component arises from sellar region and then extends to posterior fossa, which should be strongly suspected as a PFCP. The combined supra- and infratentorial approach is an ideal choice for surgical management of PFCP.

Endoscopic transventricular positioning of intracystic catheter for treatment of craniopharyngioma. Technical note

The intracystic injection of chemo- and radiotherapeutic agents was introduced for the treatment of craniopharyngioma to control tumor growth and to delay the potentially harmful effects of surgery or radiation therapy. The positioning of cyst catheters has been performed by means of direct vision, stereotactically guided insertion, and ultrasonographic and ventriculoscopic guidance. The insertion of a catheter into the cyst is not devoid of complications, with an incidence ranging up to 16%, independent of the surgical technique used. Eight patients (mean age 25.8 years) with symptomatic cystic craniopharyngioma were treated by means of an endoscopic transventricular approach for the insertion of an intracystic catheter for intratumoral therapy with interferon-alpha. A single right precoronal bur hole is made, and the frontal horn of the lateral ventricle is accessed under neuronavigation guidance. A ventricular catheter with an inserted stylet was advanced anterior to the endoscope sheath through the same cortical access as the endoscope and was guided under endoscopic view down to the cyst dome wall. The coagulated surface of the craniopharyngioma cyst was punctured and the tip of the ventricular catheter was advanced; the depth was established preoperatively on MR scans and confirmed by neuronavigation guidance. The proximal end of the cystic catheter was connected to an access chamber to be left in the subcutaneous space, and the endoscope was slowly retracted. The authors' experience favors the use of neuroendoscopic positioning of intracystic catheters as safer than open and stereotactic approaches.

Surgical management of craniopharyngiomas

Surgical treatment of craniopharyngiomas has been historically challenging and, despite advancements in microsurgical and skull base techniques, continues to pose a challenge to modern day surgeons. In particular, proponents of subtotal resection in conjunction with radiotherapy argue that this less aggressive approach can yield equivalent control rates with lower morbidity, while others argue that gross total resection is superior. Regardless of whether gross total or subtotal resection is the goal, surgical planning must include a thorough endocrine and neuro-ophthalmologic evaluation as well as imaging, and the approach, whether transsphenoidal or transcranial, must take into account the nature of the tumor and its location. In addition, optimal management of craniopharyngiomas must consist of an individualized and multidisciplinary approach not only including neurological surgery, but also including endocrinology, neuro-ophthalmology, neuropsychology, and, often, radiation-oncology.

Craniopharyngioma: historical notes

For centuries tumors have been described which today with some confidence can be diagnosed as craniopharyngiomas. It was not until 1904 Erdheim described what he called 'hypophysial duct tumors', and which Cushing later gave the name craniopharyngioma. The first operation for this neoplasm took place in 1909. It soon became evident that the outcome of surgery was rather dismal with high mortality and morbidity rates-even after corticosteroid therapy became available around 1950. Radiotherapy was introduced and later refined as radiosurgery. This paper presents a short survey of the accumulation of knowledge of craniopharyngiomas.

The evolution of the endonasal approach for craniopharyngiomas

✓Craniopharyngiomas have always been an extremely challenging type of tumor to treat. The transsphenoidal route has been used for resection of these lesions since its introduction. The authors present a historical review of the literature from the introduction of the endonasal route for resection of craniopharyngiomas until the present. Abandoned early due to technological limitations, this approach has been expanded both in its application and in its anatomical boundaries with subsequent progressive improvements in outcomes. This expansion has coincided with advances in visualization devices, imaging guidance techniques, and anatomical understanding. The progression from the use of headlights, to microscopy, to endoscopy and fluoroscopy, and finally to modern intraoperative magnetic resonance–guided techniques, combined with collaboration between otolaryngologists and neurosurgeons, has provided the framework for the development of current techniques for the resection of sellar and suprasellar craniopharyngiomas.

Craniopharyngioma in childhood

In summary, much progress has been made in our understanding of childhood craniopharyngiomas. These histologically benign but "geographically malignant" tumors are challenging to treat and require experienced clinicians from multiple disciplines including neurosurgery, radiology, hematology/oncology, ophthalmology, endocrinology, and general pediatrics to address the multiple issues that arise with diagnosis, treatment, and long-term follow-up of affected children. The study and close observation of patients who have craniopharyngiomas may also be beneficial for our general understanding of pathophysiologic processes such as the observed "growth without growth hormone" phenomenon or the well-described and studied hypothalamic obesity phenotypes.